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Background. Opioids contribute to more than 60 000 deaths annually in North America. While the expansion of overdose education and naloxone distribution (OEND) programs has been recommended in response to the opioid crisis, their effectiveness remains unclear. Objectives. To conduct an umbrella review of systematic reviews to provide a broad-based conceptual scheme of the effect and feasibility of OEND and to identify areas for possible optimization. Search Methods. We conducted the umbrella review of systematic reviews by searching PubMed, Embase, PsycINFO, Epistemonikos, the Cochrane Database of Systematic Reviews, and the reference lists of relevant articles. Briefly, an academic librarian used a 2-concept search, which included opioid subject headings and relevant keywords with a modified PubMed systematic review filter. Selection Criteria. Eligible systematic reviews described comprehensive search strategies and inclusion and exclusion criteria, evaluated the quality or risk of bias of included studies, were published in English or French, and reported data relevant to either the safety or effectiveness of OEND programs, or optimal strategies for the management of opioid overdose with naloxone in out-of-hospital settings. Data Collection and Analysis. Two reviewers independently extracted study characteristics and the quality of included reviews was assessed in duplicate with AMSTAR-2, a critical appraisal tool for systematic reviews. Review quality was rated critically low, low, moderate, or high based on 7 domains: protocol registration, literature search adequacy, exclusion criteria, risk of bias assessment, meta-analytical methods, result interpretation, and presence of publication bias. Summary tables were constructed, and confidence ratings were provided for each outcome by using a previously modified version of the Royal College of General Practitioners’ clinical guidelines. Main Results. Six systematic reviews containing 87 unique studies were included. We found that OEND programs produce long-term knowledge improvement regarding opioid overdose, improve participants’ attitudes toward naloxone, provide sufficient training for participants to safely and effectively manage overdoses, and effectively reduce opioid-related mortality. High-concentration intranasal naloxone (> 2 mg/mL) was as effective as intramuscular naloxone at the same dose, whereas lower-concentration intranasal naloxone was less effective. Evidence was limited for other naloxone formulations, as well as the need for hospital transport after overdose reversal. The preponderance of evidence pertained persons who use heroin. Author’s Conclusions. Evidence suggests that OEND programs are effective for reducing opioid-related mortality; however, additional high-quality research is required to optimize program delivery. Public Health Implications. Community-based OEND programs should be implemented widely in high-risk populations.

Objectives. To understand how Twitter bots and trolls (“bots”) promote online health content. Methods. We compared bots’ to average users’ rates of vaccine-relevant messages, which we collected online from July 2014 through September 2017. We estimated the likelihood that users were bots, comparing proportions of polarized and antivaccine tweets across user types. We conducted a content analysis of a Twitter hashtag associated with Russian troll activity. Results. Compared with average users, Russian trolls (χ 2 (1) = 102.0; P < .001), sophisticated bots (χ 2 (1) = 28.6; P < .001), and “content polluters” (χ 2 (1) = 7.0; P < .001) tweeted about vaccination at higher rates. Whereas content polluters posted more antivaccine content (χ 2 (1) = 11.18; P < .001), Russian trolls amplified both sides. Unidentifiable accounts were more polarized (χ 2 (1) = 12.1; P < .001) and antivaccine (χ 2 (1) = 35.9; P < .001). Analysis of the Russian troll hashtag showed that its messages were more political and divisive. Conclusions. Whereas bots that spread malware and unsolicited content disseminated antivaccine messages, Russian trolls promoted discord. Accounts masquerading as legitimate users create false equivalency, eroding public consensus on vaccination. Public Health Implications. Directly confronting vaccine skeptics enables bots to legitimize the vaccine debate. More research is needed to determine how best to combat bot-driven content.

Objectives. To assess if historical redlining, the US government’s 1930s racially discriminatory grading of neighborhoods’ mortgage credit-worthiness, implemented via the federally sponsored Home Owners’ Loan Corporation (HOLC) color-coded maps, is associated with contemporary risk of preterm birth (< 37 weeks gestation). Methods. We analyzed 2013–2017 birth certificate data for all singleton births in New York City (n = 528 096) linked by maternal residence at time of birth to (1) HOLC grade and (2) current census tract social characteristics. Results. The proportion of preterm births ranged from 5.0% in grade A (“best”—green) to 7.3% in grade D (“hazardous”—red). The odds ratio for HOLC grade D versus A equaled 1.6 and remained significant (1.2; P < .05) in multilevel models adjusted for maternal sociodemographic characteristics and current census tract poverty, but was 1.07 (95% confidence interval = 0.92, 1.20) after adjustment for current census tract racialized economic segregation. Conclusions. Historical redlining may be a structural determinant of present-day risk of preterm birth. Public Health Implications. Policies for fair housing, economic development, and health equity should consider historical redlining’s impacts on present-day residential segregation and health outcomes.

Background: Transgender individuals experience unique vulnerabilities to intimate partner violence (IPV) and may experience a disproportionate IPV burden compared with cisgender (nontransgender) individuals. Objectives: To systematically review the quantitative literature on prevalence and correlates of IPV in transgender populations. Search Methods: Authors searched research databases (PubMed, CINAHL), gray literature (Google), journal tables of contents, and conference abstracts, and consulted experts in the field. Authors were contacted with data requests in cases in which transgender participants were enrolled in a study, but no disaggregated statistics were provided for this population. Selection Criteria: We included all quantitative literature published before July 2019 on prevalence and correlates of IPV victimization, perpetration, or service utilization in transgender populations. There were no restrictions by sample size, year, or location. Data Collection and Analysis: Two independent reviewers conducted screening. One reviewer conducted extraction by using a structured database, and a second reviewer checked for mistakes or omissions. We used random-effects meta-analyses to calculate relative risks (RRs) comparing the prevalence of IPV in transgender individuals and cisgender individuals in studies in which both transgender and cisgender individuals were enrolled. We also used meta-analysis to compare IPV prevalence in assigned-female-sex-at-birth and assigned-male-sex-at-birth transgender individuals and to compare physical IPV prevalence between nonbinary and binary transgender individuals in studies that enrolled both groups. Main Results: We identified 85 articles from 74 unique data sets (n total  = 49 966 transgender participants). Across studies reporting it, the median lifetime prevalence of physical IPV was 37.5%, lifetime sexual IPV was 25.0%, past-year physical IPV was 16.7%, and past-year sexual IPV was 10.8% among transgender individuals. Compared with cisgender individuals, transgender individuals were 1.7 times more likely to experience any IPV (RR = 1.66; 95% confidence interval [CI] = 1.36, 2.03), 2.2 times more likely to experience physical IPV (RR = 2.19; 95% CI = 1.66, 2.88), and 2.5 times more likely to experience sexual IPV (RR = 2.46; 95% CI = 1.64, 3.69). Disparities persisted when comparing to cisgender women specifically. There was no significant difference in any IPV, physical IPV, or sexual IPV prevalence between assigned-female-sex-at-birth and assigned-male-sex-at-birth individuals, nor in physical IPV prevalence between binary- and nonbinary-identified transgender individuals. IPV victimization was associated with sexual risk, substance use, and mental health burden in transgender populations. Authors’ Conclusions: Transgender individuals experience a dramatically higher prevalence of IPV victimization compared with cisgender individuals, regardless of sex assigned at birth. IPV prevalence estimates are comparably high for assigned-male-sex-at-birth and assigned-female-sex-at-birth transgender individuals, and for binary and nonbinary transgender individuals, though more research is needed. Public Health Implications: Evidence-based interventions are urgently needed to prevent and address IPV in this high-risk population with unique needs. Lack of legal protections against discrimination in employment, housing, and social services likely foster vulnerability to IPV. Transgender individuals should be explicitly included in US Preventive Services Task Force recommendations promoting IPV screening in primary care settings. Interventions at the policy level as well as the interpersonal and individual level are urgently needed to address epidemic levels of IPV in this marginalized, high-risk population.

Background. Corporate interests have the potential to influence public debate and policymaking by influencing the research agenda, namely the initial step in conducting research, in which the purpose of the study is defined and the questions are framed. Objectives. We conducted a scoping review to identify and synthesize studies that explored the influence of industry sponsorship on research agendas across different fields. Search Methods. We searched MEDLINE, Scopus, and Embase (from inception to September 2017) for all original research and systematic reviews addressing corporate influence on the research agenda. We hand searched the reference lists of included studies and contacted experts in the field to identify additional studies. Selection Criteria. We included empirical articles and systematic reviews that explored industry sponsorship of research and its influence on research agendas in any field. There were no restrictions on study design, language, or outcomes measured. We excluded editorials, letters, and commentaries as well as articles that exclusively focused on the influence of industry sponsorship on other phases of research such as methods, results, and conclusions or if industry sponsorship was not reported separately from other funding sources. Data Collection and Analysis. At least 2 authors independently screened and then extracted any quantitative or qualitative data from each study. We grouped studies thematically for descriptive analysis by design and outcome reported. We developed the themes inductively until all studies were accounted for. Two investigators independently rated the level of evidence of the included studies using the Oxford Centre for Evidence-Based Medicine ratings. Main Results. We included 36 articles. Nineteen cross-sectional studies quantitatively analyzed patterns in research topics by sponsorship and showed that industry tends to prioritize lines of inquiry that focus on products, processes, or activities that can be commercialized. Seven studies analyzed internal industry documents and provided insight on the strategies the industry used to reshape entire fields of research through the prioritization of topics that supported its policy and legal positions. Ten studies used surveys and interviews to explore the researchers’ experiences and perceptions of the influence of industry funding on research agendas, showing that they were generally aware of the risk that sponsorship could influence the choice of research priorities. Conclusions. Corporate interests can drive research agendas away from questions that are the most relevant for public health. Strategies to counteract corporate influence on the research agenda are needed, including heightened disclosure of funding sources and conflicts of interest in published articles to allow an assessment of commercial biases. We also recommend policy actions beyond disclosure such as increasing funding for independent research and strict guidelines to regulate the interaction of research institutes with commercial entities. Public Health Implications. The influence on the research agenda has given the industry the potential to affect policymaking by influencing the type of evidence that is available and the kinds of public health solutions considered. The results of our scoping review support the need to develop strategies to counteract corporate influence on the research agenda.

Objectives. To examine trends in opioid overdose deaths by race/ethnicity from 2018 to 2019 across 67 HEALing Communities Study (HCS) communities in Kentucky, New York, Massachusetts, and Ohio. Methods. We used state death certificate records to calculate opioid overdose death rates per 100 000 adult residents of the 67 HCS communities for 2018 and 2019. We used Poisson regression to calculate the ratio of 2019 to 2018 rates. We compared changes by race/ethnicity by calculating a ratio of rate ratios (RRR) for each racial/ethnic group compared with non-Hispanic White individuals. Results. Opioid overdose death rates were 38.3 and 39.5 per 100 000 for 2018 and 2019, respectively, without a significant change from 2018 to 2019 (rate ratio = 1.03; 95% confidence interval [CI] = 0.98, 1.08). We estimated a 40% increase in opioid overdose death rate for non-Hispanic Black individuals (RRR = 1.40; 95% CI = 1.22, 1.62) relative to non-Hispanic White individuals but no change among other race/ethnicities. Conclusions. Overall opioid overdose death rates have leveled off but have increased among non-Hispanic Black individuals. Public Health Implications. An antiracist public health approach is needed to address the crisis of opioid-related harms. (Am J Public Health. 2021;111(10):1851–1854. https://doi.org/10.2105/AJPH.2021.306431 )

Background. Research has found a strong link between ageism, in the form of negative stereotypes, prejudice, and discrimination toward older people, and risks to their physical and mental health. Little is known, however, about the effectiveness of strategies to reduce ageism. Objectives. To assess the relative effects of 3 intervention types designed to reduce ageism among youths and adults—education, intergenerational contact, and combined education and intergenerational contact—by conducting a systematic review and meta-analysis. Search Methods. We searched PubMed, PsycINFO, AgeLine, EBSCO, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Index Medicus, Database of Abstracts of Reviews of Effects (DARE), Epistemonikos, Cochrane Database of Systematic Reviews, Campbell Collaboration, PROSPERO, GreyLit, and OpenGrey. We identified additional records by hand-searching reference lists of relevant review articles as well as records included in the meta-analysis. Two independent reviewers completed the search and screening process. Selection Criteria. Eligible studies were those that (1) evaluated an intervention designed to reduce ageism, (2) examined at least 1 ageism outcome in relation to older adults, (3) used a design with a comparison group (randomized or nonrandomized), and (4) were published after 1970, when the ageism concept was developed. Data Collection and Analysis. Two independent reviewers extracted study-level data from records using a common data collection spreadsheet. They also assessed study quality by using the Cochrane Risk of Bias Tool, and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool to assess quality of outcome evidence. Primary outcomes were attitudes toward older people and accuracy of knowledge about aging and older people. Secondary outcomes included comfort with older adults, anxiety about one’s own aging, and interest in working in the field of geriatrics or gerontology. We carried out meta-analyses with statistical mixed models. Main Results. We identified 63 eligible studies (1976–2018) with a total sample of 6124 participants. Ageism interventions demonstrated a strongly significant effect on attitudes (differences of standardized mean differences [d D ] = 0.33; P < .001), knowledge (d D  = 0.42; P < .001), and comfort (d D  = 0.50; P < .001), but no significant effect on anxiety (d D  = 0.13; P = .33) or working with older adults (d D  = −0.09; P = .40). Combined interventions with education and intergenerational contact showed the largest effects on attitudes. We found stronger effects for females and for adolescent and young adult groups. Authors’ Conclusions. Interventions are associated with substantial reduction in ageism and should be part of an international strategy to improve perceptions of older people and the aging process. Additional research using more rigorous designs to examine the effects of interventions is strongly recommended. Public Health Implications. Ageism has well-established negative effects on the physical and mental health of older people. Findings suggest that relatively low-cost, feasible strategies involving education and intergenerational contact can serve as the basis of effective interventions to reduce ageism.

Objectives. To understand important changes in co-occurring opioid and nonopioid drug use (i.e., polysubstance use) within the opioid epidemic in the United States. Methods. We analyzed survey data on the past month co-use of prescription and illicit opioids and 12 nonopioid psychoactive drug classes from a national sample of 15 741 persons entering treatment of opioid use disorder. Results. Past-month illicit opioid use increased from 44.8% in 2011 to 70.1% in 2018, while the use of prescription opioids alone dropped from 55.2% to 29.9%, yet overall remained high (94.5% to 85.2%). Past-month use of at least 1 nonopioid drug occurred in nearly all participants (> 90%), with significant increases in methamphetamine (+85%) and decreases across nonopioid prescription drug classes (range: −40% to –68%). Conclusions. Viewing opioid trends in a “silo” ignores the fact not only that polysubstance use is ubiquitous among those with opioid use disorder but also that significant changes in polysubstance use should be monitored alongside opioid trends. Public Health Implications. Treatment, prevention, and policymaking must address not only the supply and demand of a singular drug class but also the global nature of substance use overall.

Objectives. To document the cumulative childhood risk of different levels of involvement with the child protection system (CPS), including terminations of parental rights (TPRs). Methods. We linked vital records for California’s 1999 birth cohort (n = 519 248) to CPS records from 1999 to 2017. We used sociodemographic information captured at birth to estimate differences in the cumulative percentage of children investigated, substantiated, placed in foster care, and with a TPR. Results. Overall, 26.3% of children were investigated for maltreatment, 10.5% were substantiated, 4.3% were placed in foster care, and 1.1% experienced a TPR. Roughly 1 in 2 Black and Native American children were investigated during childhood. Children receiving public insurance experienced CPS involvement at more than twice the rate of children with private insurance. Conclusions. Findings provide a lower-bound estimate of CPS involvement and extend previous research by documenting demographic differences, including in TPRs. Public Health Implications. Conservatively, CPS investigates more than a quarter of children born in California for abuse or neglect. These data reinforce policy questions about the current scope and reach of our modern CPS.

Objectives. To examine associations between state-level variation in abortion-restricting policies in 2015 and total maternal mortality (TMM), maternal mortality (MM), and late maternal mortality (LMM) from 2015 to 2018 in the United States. Methods. We derived an abortion policy composite index for each state based on 8 state-level abortion-restricting policies. We fit ecological state-level generalized linear Poisson regression models with robust standard errors to estimate 4-year TMM, MM, and LMM rate ratios and 95% confidence intervals (CIs) associated with a 1-unit increase in the abortion index, adjusting for state-level covariates. Results. States with the higher score of abortion policy composite index had a 7% increase in TMM (adjusted rate ratio [ARR] = 1.07; 95% CI = 1.02, 1.12) compared with states with lower abortion policy composite index, after we adjusted for state-level covariates. Among individual abortion policies, states with a licensed physician requirement had a 51% higher TMM (ARR = 1.51; 95% CI = 1.15, 1.99) and a 35% higher MM (ARR = 1.35; 95% CI = 1.09, 1.67), and states with restrictions on Medicaid coverage of abortion care had a 29% higher TMM (ARR = 1.29; 95% CI = 1.03, 1.61). Conclusions. Restricting access to abortion care at the state level may increase the risk for TMM.